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SpiritPharmacist.com 12/19 Antidepressant & Psychedelic Drug Interaction Chart This chart is not intended to be used to make medical decisions and is for informational purposes only. It was constructed using data whenever possible, although extrapolation from known information was also used to inform risk. Any decision to start, stop, or taper medication and/or use psychedelic drugs should be made in conjunction with your healthcare provider(s). It is recommended to not perform any illicit activity. Antidepressant Phenethylamines Tryptamines MAOI-containing Ketamine Ibogaine -MDMA, mescaline -Psilocybin, LSD -Ayahuasca, Syrian Rue SSRIs Taper & discontinue at least 2 Consider taper & Taper & discontinue at least 2 Has been studied and Taper & discontinue at · Paroxetine (Paxil) weeks prior (all except discontinuation at least 2 weeks weeks prior (all except found effective both with least 2 weeks prior (all · Sertraline (Zoloft) fluoxetine) or 6 weeks prior prior (all except fluoxetine) or 6 fluoxetine) or 6 weeks prior and without concurrent except fluoxetine) or 6 · Citalopram (Celexa) (fluoxetine only) due to loss of weeks prior (fluoxetine only) (fluoxetine only) due to use of antidepressants weeks prior (fluoxetine · Escitalopram (Lexapro) psychedelic effect due to potential loss of potential risk of serotonin only) due to risk of · Fluxoetine (Prozac) psychedelic effect syndrome additive QTc interval · Fluvoxamine (Luvox) MDMA is unable to cause Recommended prolongation, release of serotonin when the Chronic antidepressant use may Life threatening toxicities can to be used in conjunction arrhythmias, or SPARI serotonin reuptake pump is result in down-regulation of occur with these with oral antidepressants cardiotoxicity · Vibryyd (Vilazodone) blocked. This leads to drastically 5HT2A receptors and blunted combinations and is strictly by esketamine · Trintellix (Vortioxetine) reduced effects [1-7] psychedelic experiences [8, 9]. contraindicated [10, 11] manufacturer Some antidepressants are This does not seem to affect liver (CYP2D6) inhibitors SNRI psilocybin for some and have been shown to ·Venlafaxine (Effexor) double ibogaine blood ·Duloxetine (Cymbalta) concentrations [12] ·Desvenlafaxine (Pristiq) ·Levomilnacipran (Fetzima) DNRI Increased effects of MDMA with Loss of effect not predicted to Taper & discontinue at least 2 Taper & discontinue at · Bupropion (Wellbutrin) higher blood concentrations for occur, consider taper & weeks prior due to potential least 2 weeks prior to use. longer [13]. May increase risk of discontinuation depending on of adverse effects, however May increase risk of seizures in combination. Caution goals of psychedelic use serotonin syndrome unlikely seizures in combination. in combination. Consider taper to occur [14] & discontinuation of bupropion. CYP2D6 inhibitor with Alternatively, a 25% reduced potential to increase dose of MDMA if bupropion is ibogaine blood continued. cocnentrations · Mirtazapine (Remeron) Taper & discontinue at least 2 weeks prior due to loss of psychedelic effect Taper & discontinue at least 2 week prior due to Mirtazapine does not block the serotonin reuptake pump like SSRI, SPARI, or SNRI antidepressants. It risk of additive QTc blocks the 5HT2A receptor, thus is predicted to cause a blunting or loss of psychedelic effects. It has interval prolongation, not been associated with serotonin syndrome with MAOIs [14] arrhythmias, or cardiotoxicity SSRI = selective serotonin reuptake inhibitor SPARI = serotonin partial agonist and reuptake inhibitor SNRI = serotonin norepinephrine reuptake inhibitor DNRI = dopamine norepinephrine reuptake inhibitor MAOI = monoamine oxidase inhibitor SERT = serotonin reuptake pump 5HT2A = serotonin 2A receptor 1 SpiritPharmacist.com 12/19 Antidepressant Phenethylamines Tryptamines MAOI-containing Ketamine Ibogaine -MDMA, mescaline -Psilocybin, LSD -Ayahuasca, Syrian Rue Tricyclic Antidepressant (TCA) Taper & discontinue at Consider taper & Taper & discontinue at least 2 Has been studied Taper & discontinue at · Amitriptyline (Elavil) least 2 weeks prior due to discontinuation at least 2 weeks prior due to potential risk of and found effective least 2 weeks prior due · Nortriptyline (Pamelor) loss of psychedelic effect weeks prior due to potential serotonin syndrome. Risk is both with and to risk of additive QTc · Clomipramine (Anafranil) intensified effects highest with clomipramine, without concurrent interval prolongation, · Imipramine (Tofranil) MDMA is unable to cause imipramine, and chlorpheniramine use of arrhythmias, or · Desipramine (Norpramin) release of serotonin when Chronic TCA use was reported [14] antidepressants cardiotoxicity · Chlorpheniramine the serotonin reuptake to increase the subjective pump is blocked. This leads effects of LSD [15] Life threatening toxicities can Some antidepressants to drastically reduced occur with these combinations and Recommended are liver (CYP2D6) effects is strictly contraindicated to be used in inhibitors and have conjunction with been shown to double oral antidepressants ibogaine blood by esketamine concentrations · Trazodone (Desyrel) Taper & discontinue at least 5 days prior due to loss of psychedelic effect manufacturer Taper & discontinue at least 1 week prior due Trazodone blocks 5HT2A receptors at lower doses (25-150mg) and starts blocking the serotonin to risk of additive QTc reuptake pump (SERT) at >150mg [14]. It has an active metabolite that also blocks 5HT2A receptors interval prolongation, as well as modulating many other 5HT receptors arrhythmias, or cardiotoxicity · Buspirone (Buspar) Taper & discontinue at least 5 days prior due to loss of psychedelic effect Taper & discontinue at least 5 days prior due Buspirone is a non-psychedelic partial agonist at serotonin receptors, thus may display blunting of to potential risk of psychedelic effects due to competitive inhibition when used in combination with psychedelics [16]. toxicity It does not inhibit the reuptake of nor release neurotransmitters, thus risk of serotonin syndrome with MAOIs is low MAO-A Inhibitors* Taper & discontinue at Consider taper & Taper & discontinue at least 2 Taper & discontinue at · Phenelzine (Nardil) least 2 weeks prior due to discontinuation at least 2 weeks prior least 10 days prior due · Isocarboxazid (Parnate) potential risk of serotonin weeks prior due to potential to potential risk of · Tranylcypromine (Marplan) syndrome or hypertensive loss of psychedelic effect [15] Additive use of MAOIs may cause toxicity [20] · Moclobemide crisis [17] intensified experiences or Contraindicated with cardiovascular collapse (fainting or *chronic use tryptamine 5-MeO-DMT [18, dangerously low blood pressure) 19] MAO-B inhibitors Intensified effects, risk of Intensified effects possible, risk · Selegeline (Emsam) serotonin syndrome at of serotonin syndrome at doses ≥9mg/day doses ≥9mg/day with 5-MeO- DMT; psilocybin or LSD likely Taper & discontinue at have low risks of physical least 2 weeks prior, toxicity in combination especially if dose ≥9mg/day SSRI = selective serotonin reuptake inhibitor SPARI = serotonin partial agonist and reuptake inhibitor SNRI = serotonin norepinephrine reuptake inhibitor DNRI = dopamine norepinephrine reuptake inhibitor MAOI = monoamine oxidase inhibitor SERT = serotonin reuptake pump 5HT2A = serotonin 2A receptor 2 SpiritPharmacist.com 12/19 References: 1. Farre, M., et al., Pharmacological interaction between 3,4-methylenedioxymethamphetamine (ecstasy) and paroxetine: pharmacological effects and pharmacokinetics. J Pharmacol Exp Ther, 2007. 323(3): p. 954-62. 2. Hysek, C.M., et al., Duloxetine inhibits effects of MDMA ("ecstasy") in vitro and in humans in a randomized placebo-controlled laboratory study. PLoS One, 2012. 7(5): p. e36476. 3. Liechti, M.E. and F.X. Vollenweider, The serotonin uptake inhibitor citalopram reduces acute cardiovascular and vegetative effects of 3,4- methylenedioxymethamphetamine ('Ecstasy') in healthy volunteers. J Psychopharmacol, 2000. 14(3): p. 269-74. 4. Piper, B.J., et al., Dissociation of the neurochemical and behavioral toxicology of MDMA ('Ecstasy') by citalopram. Neuropsychopharmacology, 2008. 33(5): p. 1192-205. 5. Stein, D.J. and J. Rink, Effects of "Ecstasy" blocked by serotonin reuptake inhibitors. J Clin Psychiatry, 1999. 60(7): p. 485. 6. Tancer, M. and C.E. Johanson, The effects of fluoxetine on the subjective and physiological effects of 3,4-methylenedioxymethamphetamine (MDMA) in humans. Psychopharmacology (Berl), 2007. 189(4): p. 565-73. 7. Gudelsky, G.A. and J.F. Nash, Carrier-mediated release of serotonin by 3,4-methylenedioxymethamphetamine: implications for serotonin-dopamine interactions. J Neurochem, 1996. 66(1): p. 243-9. 8. Bonson, K.R., J.W. Buckholtz, and D.L. Murphy, Chronic administration of serotonergic antidepressants attenuates the subjective effects of LSD in humans. Neuropsychopharmacology, 1996. 14(6): p. 425-36. 9. Carhart-Harris, R.L. and D.J. Nutt, Serotonin and brain function: a tale of two receptors. Journal of Psychopharmacology (Oxford, England), 2017. 31(9): p. 1091-1120. 10. Callaway, J.C. and C.S. Grob, Ayahuasca preparations and serotonin reuptake inhibitors: a potential combination for severe adverse interactions. J Psychoactive Drugs, 1998. 30(4): p. 367-9. 11. Malcolm, B.J. and K.C. Lee, Ayahuasca: An ancient sacrament for treatment of contemporary psychiatric illness? Ment Health Clin, 2017. 7(1): p. 39-45. 12. Glue, P., et al., Influence of CYP2D6 activity on the pharmacokinetics and pharmacodynamics
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